Bipolar Disorder in Children and Youth: Information for Families

Summary: Bipolar disorder is a condition marked by severe highs and lows in moods to the point that it causes problems. High periods or 'manic episodes' are marked by abnormally high or irritable moods, along with increased energy and decreased need for sleep. Low periods are marked by low energy and depressed moods. The good news is that there are many things that patients and loved ones can do in order to cope with bipolar.

What Is Bipolar Disorder?

All of us have changes and swings in our mood which are normal. There are times when our mood is up, and we have more energy and excitement about things. There are other times when our moods are down, and we have less energy.

However, people with bipolar disorder have periods of extreme mood change that cause serious problems in their lives.

In the classic form of bipolar, people have episodes of depression and of mania, when their mood, energy, thinking and behaviour gets stuck for a period of time at a very low or a very high level. Hence the term, "bipolar", which refers to the two ("bi-") different poles of mood ("-polar").

High energy periods, or manic episodes / mania consists of periods with symptoms such as:

Persistent period of high energy, lasting days to weeks, during which time a person has a decreased need for sleep (e.g. only needs a few hours of sleep, or even none at all, yet still has lots of energy the next day).

Extremes of mood, which may be excessively "high" (overly good, euphoric mood) and at times extreme irritability.[this would be mixed not manic]

Racing thoughts, i.e. thought flow increased speed

Pressured speech, i.e. talking very fast

Distractibility, can't concentrate well

Increased self-esteem, which can be the point where one has grandiose, unrealistic ideas about oneself

Increased activity

Poor judgment, decision-making and impulsive behaviours such as making large purchases, gambling or other risky behaviours such as doing drugs or increased sex drive.

Lack of insight that anything is wrong, such that the person may deny that there is a problem. But in a classic manic episode, it is obvious to friends and family that something is wrong as this (behaviour) represents a change for this person. * not sure if we want behaviour persay, but maybe need to be more specific than "this".*

While some individuals with bipolar disorder experience full-blown manic episodes, others also experience a mild to moderate level of mania, known as "hypomania". Hypomania is milder than mania, but it is a major change in functioning for the individual and it may lead into full-blown mania, or major depression.

What goes up must come down, which is why periods of high energy (manic episodes) are typically followed by low energy periods.

Low energy episodes or depressive episodes may occur to the extreme such that the person may have:

Extremely low energy for days or weeks, with increased need for sleep

Extremely low, depressed mood that is stuck and not reactive to what is happening around the person

Feelings of guilt, worthlessness, or helplessness

Loss of interest or pleasure in activities

Due to low mood, the person may have thoughts that life isn't worth living, even to the point of thinking about making attempts to end one's life.

Mood episodes may also get so extreme that the person loses touch with reality, and may have symptoms of psychosis such as:

Hallucinations, which includes hearing or seeing things which aren't actually there. For example, hearing voices or seeing people.

Delusions, which are false beliefs with no basis in reality. For example, in a manic phase, one might believe that they can fly, or that they are a famous celebrity. On the other hand in a depressive phase, one might feel extreme irrational guilt.

The Positive Side of Bipolar

Why do some people have bipolar? Studies show that the same genes that contribute to bipolar disorder may very well be the same genes linked to intelligence and creativity (Smith, 2015). Throughout human history, there are numerous notable examples of famous people that have had bipolar disorder. Bipolar traits and bipolar disorder may simply be the genetic price for intelligence and creativity.

How Common is Bipolar Disorder?

The exact prevalence of bipolar disorder in children and youth remains controversial (Moreno et al., 2007). On one hand, one study suggested that it occurs in 1% of children/youth at any given time (Costello et al., Lewinsohn et al). On the other hand, in a large UK study there were no cases of bipolar disorder in children (Meltzer, 2000).

With adults, there is less controversy. It is believed that bipolar I or II occurs in up to 4% of adults in the USA (Kessler, 2005).

When Does Bipolar Disorder Start?

Bipolar usually starts in late teens or adulthood. In fact, about 50-66% of adults with bipolar report that their symptoms started before age 19 (Chang, 2007).

If You Suspect Bipolar...

If you suspect that your child may have bipolar disorder, take your child to be seen by your primary care provider (such as a family doctor or paediatrician) to make sure there aren't any medical problems (such as hormone imbalances) that might be causing or contributing to your child's symptoms.

Types of Bipolar Disorder

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual used by mental health professionals to diagnose mental health conditions, the main types of bipolar disorderare:

Bipolar I, classically consisting of manic and depressive episodes. Many individuals present first with major depressive episodes when younger and do not go onto develop manic episodes until older.

Bipolar II, consisting of hypomanic episodes and major depressive episodes.

Cyclothymia, consisting of hypomanic episodes with depressive episodes (but not severe enough to be major depressive episodes per se).

Bipolar Not Otherwise Specified (NOS), which is used to describe individuals with mood swings that cause problems, but which do not fit into any of the other above categories. In the past, many children/youth used to be diagnosed with BIpolar NOS, but it turns out for many of them, the diagnosis of disruptive mood dysregulation disorder (DMDD) may be more appropriate.

In addition, other terms used include:

Rapid-cycling: when a person has at least 4 episodes per year. This type is seen about 5-15% of patients.

Mixed state: when a person has both manic and depressive symptoms occurring at the same time

Diagnosis of Bipolar Disorder

Psychologists and psychiatrists are the main professionals qualified to make a diagnosis of bipolar disorder.

During the assessment, the doctor asks the patient (and family members) about symptoms, the developmental and school history and the family history in order to make a determination about diagnosis and recommendations.

Getting a proper diagnosis is important. Because bipolar disorder is generally treated with medications, giving someone a diagnosis will generally lead to medication treatment. Misdiagnosing someone with bipolar disorder when they don't have it can lead to unnecessary medication use along with medication side effects. At the same time, not diagnosing someone who truly has it means that that person will miss out on potentially life-changing treatment.

At this time, there is not yet any blood test, brain scan or other diagnostic test that can help with the diagnosis of bipolar disorder.

Other Conditions May Contribute to, or Look Like Bipolar

There are other conditions that can also contribute to mood problems (e.g. mood swings, anger or rage). If any of these are present, they can be addressed as well:

ADHD is defined as severe problems with inattention and distractibility, and individuals with ADHD may have constant problems with anger and low frustration tolerance

Sensory processing disorders (SPD):

SPD is a condition where individuals can be overwhelmed by sensory input (e.g. touch, sound, light), reacting with anger, mood swings and rages

Autistic spectrum disorders (ASD)

ASD is a condition where individuals have extreme difficulties understanding other people, and tend to be extremely rigid and inflexible

Learning disorders (LD)

LDs are conditions where individuals have problems with learning, and as a result, this can be extremely frustrating, leading to anger and mood problems particularly at school

Fetal alcohol spectrum disorders (FASD)

FASD occurs when a developing baby is exposed to alcohol while still in the womb

Treatments for Bipolar Disorder

There are various ways to treat bipolar disorder, and can include:

Teaching the patient and family members about bipolar disorder, and self-help (i.e. coping strategies)

Ensuring that the child/youth has a strong support network at home, and/or school and/or work.

Medications

Counselling / psychotherapy (talk therapy)

Treatments for Bipolar: Medications

Studies show that individuals with bipolar disorder have brain differences compared to other people. In other words, bipolar disorder is not your child's fault, nor is it due to choice or bad behavior, just like the way in which other brain conditions such as epilepsy, multiple sclerosis are also similarly not the person's fault.

Medications

Because bipolar disorder has such a strong biological basis, medications are often necessary in the treatment of (true) bipolar disorder.

Common medications used in the treatment of bipolar disorder include:

Lithium

Divalproex (trade name Epival)

Lamotrigine (trade name Lamictal)

Olanzapine (trade name Zyprexa)

Quetiapine (trade name Seroquel)

Risperidone (trade name Risperdal)

Aripiprazole (trade name Abilify)

For more information about medications, speak to your doctor.

Self-Help: Taking Care of the Body and Brain

The following strategies are particularly important for people with bipolar disorder, though note that these strategies are safe and healthy for anyone's brain:

Keep regular, daily routines, which will help set your child's internal clock (Frank, 2007). As much as possible, set the same times every day (weekends and weekdays) for:

a) Your child's bedtime and wakeup time.

b) What time your child sees the first person in his/her day
c) Mealtimes, like breakfast, lunch, dinner

Ensure your child is getting enough sleep. The average child/youth needs at least 9-11 hours of sleep. Unfortunately, all too many children/youth (and adults) use electronic devices in the evening, which tricks the brain into thinking it is daytime.

Try your best to:

Limit the electronics, and come up with a good sleep routine to ensure sleep.

Keep the same times on weekends as well as weekdays. People with bipolar disorder should not be staying up late on weekends, because this can be very disruptive for their internal clock -- it is like having ‘mini' jet lag every weekend. Note that a study showed the effectiveness of "dark therapy", i.e. exposing patients to darkness from 6 PM to 8 AM for a few days helped improve manic symptoms such that patients had less need for medication and were discharged earlier from hospital (Barbini, 2005).

Regular physical activity, ideally outdoors. Studies show the effectiveness of being active, particularly outside. For more information on how to become more physically active, contact the website of the Public Health Agency of Canada at http://www.phac-aspc.gc.ca/pau-uap/paguide/. For youth that have trouble with team sports, individual sports (such as weightlifting, martial arts) may be more helpful.

Healthy diet with regular meals. Ensure that your child has regular meals and snacks. Not only is this important for good nutrition, but also helps set the body's internal clock.

Avoid stimulants because they may trigger manic episodes in bipolar. This includes: street drugs such as amphetamines, ‘uppers' or ‘speed'. Even milder stimulants such as coffee or prescription medications for ADHD (such as methylphenidate) need to be monitored closely by a physician.

Be cautious if your child is prescribed antidepressants. For people with bipolar, the use of antidepressant medication carries a risk of causing manic episodes, so close monitoring is required by a physician. For someone with a true diagnosis of bipolar, if antidepressants are used, they are usually used in conjunction with a mood stabilizer such as lithium.

Self-Help: Supporting Your Loved One with Bipolar

Children with bipolar disorder tend to have troubles with "emotional regulation", the ability to regulate and control their feelings. The good news is that there are many things that you can do, that over time, will help your child to develop emotional regulation skills.

Help your child express pleasant feelings by labelling and validating those feelings. When your child is happy, validate the happy feelings, for example:

Child/youth: "Look, I got to the next level in the game!" (looking excited)
Parent: "It looks like that makes you so happy... I'm glad to see you're so happy..."

It is possible that you may not agree with why your child is so happy (e.g. video game binge or doing drugs), but at least you can start with connecting by agreeing that they want to be happy.

Validate your child's feelings and emotions when your child is upset. When your child is upset, help your child label and express their feelings. This is not always easy, particularly if your child is angry or upset at you.

Child: "I hate you! You're the worst parent ever!"
Parent (to child): "Wow! You're so angry right now... You're angry at me because I said no... I know, its not easy when I say no..."

You may not agree with the reason why your child is angry, but helping your child use his/her words is one of the first steps to helping your child regulate the anger...

Tell your child that you are concerned about him or her, and be available and support your loved one with bipolar disorder. Ask your child how s/he would like to be supported.

Parent: "I'm concerned about you and want to be there for you. How can I support you? How do you want me to be help?"

Typical ways that teens want parents to support them are simply 1) listening to the child, without giving advice, 2) listening and giving advice, 3) simply spending time together, or doing fun activities.

Don't give advice if your child isn't ready to receive it. Advice is better accepted when the other person gives you permission to receive it. Simply lecturing or telling the other person what to do may not work as well, particularly with independence-seeking teens, because this may lead him/her to withdraw.

You might say: "I'm worried about you... Can I give you some advice?"

If it is a serious situation where one's physical safety is at risk, you may have to intervene.

But if it is not, you may have to just back off, and focus on building up the trust until your child/youth is ready for your advice. You might then say: "That's okay. I respect that you want to be independent. I'm here, whenever you're ready..."

Later on, continue building up your relationship with your child by ensuring that you spend 1:1 time together with your child.

Help the person get connected with professional help. Talk to your child about seeing a doctor, and take your child to see a doctor, for example:

Parent: "Its been awhile since you've seen the doctor for a checkup, so I think it would be a good idea for you to go."

If your child/youth has a strong need for independence, then perhaps give your child/youth some limited choices, for example:

Parent: "Its non-negotiable that we are seeing your doctor. But you can choose when we go... Do you want the appointment in the morning or the afternoon?"

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.

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Medication Information

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What medications are used to treat bipolar disorder?
Bipolar disorder, also called manic-depressive illness, is commonly treated with mood stabilizers. Sometimes, antipsychotics and antidepressants are used along with a mood stabilizer.
Mood stabilizers
People with bipolar disorder usually try mood stabilizers first. In general, people continue treat...

Bipolar disorder, also called manic-depressive illness, is commonly treated with mood stabilizers. Sometimes, antipsychotics and antidepressants are used along with a mood stabilizer.

Mood stabilizers

People with bipolar disorder usually try mood stabilizers first. In general, people continue treatment with mood stabilizers for years. Lithium is a very effective mood stabilizer. It was the first mood stabilizer approved by the FDA in the 1970's for treating both manic and depressive episodes.

Anticonvulsant medications also are used as mood stabilizers. They were originally developed to treat seizures, but they were found to help control moods as well. One anticonvulsant commonly used as a mood stabilizer is valproic acid, also called divalproex sodium (Depakote). For some people, it may work better than lithium.6 Other anticonvulsants used as mood stabilizers are carbamazepine (Tegretol), lamotrigine (Lamictal) and oxcarbazepine (Trileptal).

Atypical antipsychotics

Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, antipsychotics are used along with other medications.

Antipsychotics used to treat people with bipolar disorder include:

Olanzapine (Zyprexa), which helps people with severe or psychotic depression, which often is accompanied by a break with reality, hallucinations, or delusions7

Aripiprazole (Abilify), which can be taken as a pill or as a shot

Risperidone (Risperdal)

Ziprasidone (Geodon)

Clozapine (Clorazil), which is often used for people who do not respond to lithium or anticonvulsants.8

Antidepressants

Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder. Fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft) are a few that are used. However, people with bipolar disorder should not take an antidepressant on its own. Doing so can cause the person to rapidly switch from depression to mania, which can be dangerous.9 To prevent this problem, doctors give patients a mood stabilizer or an antipsychotic along with an antidepressant.

Research on whether antidepressants help people with bipolar depression is mixed. An NIMH-funded study found that antidepressants were no more effective than a placebo to help treat depression in people with bipolar disorder. The people were taking mood stabilizers along with the antidepressants. You can find out more about this study, called STEP-BD (Systematic Treatment Enhancement Program for Bipolar Disorder), here.10

What are the side effects?

Treatments for bipolar disorder have improved over the last 10 years. But everyone responds differently to medications. If you have any side effects, tell your doctor right away. He or she may change the dose or prescribe a different medication.

Different medications for treating bipolar disorder may cause different side effects. Some medications used for treating bipolar disorder have been linked to unique and serious symptoms, which are described below.

Lithium can cause several side effects, and some of them may become serious. They include:

If a person with bipolar disorder is being treated with lithium, he or she should visit the doctor regularly to check the levels of lithium in the blood, and make sure the kidneys and the thyroid are working normally.

Some possible side effects linked with valproic acid/divalproex sodium include:

Changes in weight

Nausea

Stomach pain

Vomiting

Anorexia

Loss of appetite.

Valproic acid may cause damage to the liver or pancreas, so people taking it should see their doctors regularly.

Valproic acid may affect young girls and women in unique ways. Sometimes, valproic acid may increase testosterone (a male hormone) levels in teenage girls and lead to a condition called polycystic ovarian syndrome (PCOS).11,12 PCOS is a disease that can affect fertility and make the menstrual cycle become irregular, but symptoms tend to go away after valproic acid is stopped.13 It also may cause birth defects in women who are pregnant.

Lamotrigine can cause a rare but serious skin rash that needs to be treated in a hospital. In some cases, this rash can cause permanent disability or be life-threatening.

In addition, valproic acid, lamotrigine, carbamazepine, oxcarbazepine and other anticonvulsant medications (listed in the chart at the end of this document) have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.

Other medications for bipolar disorder may also be linked with rare but serious side effects. Always talk with the doctor or pharmacist about any potential side effects before taking the medication.

For information on side effects of antipsychotics, see the section on medications for treating schizophrenia.

For information on side effects and FDA warnings of antidepressants, see the section on medications for treating depression.

How should medications for bipolar disorder be taken?

Medications should be taken as directed by a doctor. Sometimes a person's treatment plan needs to be changed. When changes in medicine are needed, the doctor will guide the change. A person should never stop taking a medication without asking a doctor for help.

There is no cure for bipolar disorder, but treatment works for many people. Treatment works best when it is continuous, rather than on and off. However, mood changes can happen even when there are no breaks in treatment. Patients should be open with their doctors about treatment. Talking about how treatment is working can help it be more effective.

It may be helpful for people or their family members to keep a daily chart of mood symptoms, treatments, sleep patterns, and life events. This chart can help patients and doctors track the illness. Doctors can use the chart to treat the illness most effectively.

Because medications for bipolar disorder can have serious side effects, it is important for anyone taking them to see the doctor regularly to check for possibly dangerous changes in the body.

Reprints:

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School Letter

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Counseling can help children with bipolar disorder, and everyone around them, to understand that their symptoms reflect a biological illness with complex genetic and environmental origins--not personality or an oppositional attitude. Counseling also can reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child...

Counseling can help children with bipolar disorder, and everyone around them, to understand that their symptoms reflect a biological illness with complex genetic and environmental origins--not personality or an oppositional attitude. Counseling also can reduce the impact of symptoms on daily life. A variety of psychological interventions can be helpful, and parents should discuss their child's particular needs with their clinician to determine which psychological treatments could be most beneficial for their child.

Individual psychotherapy may be useful for young people with bipolar disorder, particularly when there are ongoing stressors in their lives that make symptoms worse. Children with the disorder often carry a sense of failure, as if the illness was their fault. In many cases, they are aware that when they are unable to control their behavior, they may hurt people closest to them, which can increase their sense of self-blame. Individual psychotherapy can help young people become aware of and address these feelings.

Cognitive Behavior Therapy (CBT) helps a child or adolescent to become aware of, and to describe, negative thoughts, feelings or reactions. A trained clinician guides the child to think of new, more positive alternatives. The young person is then given a chance to practice new thoughts, feelings, or reactions outside the clinical visit, and to discuss his or her experiences with the clinician afterwards. These methods are based upon practices that have helped many children and adolescents.

Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child with a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.

Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting

School-based counseling can be effective in helping a child with bipolar disorder navigate the social, behavioral, and academic demands of the school setting

Special thanks to Dr. Bostic and the School Psychiatry Program at Massachusetts General Hospital for permission to reproduce these recommendations.

For more information, visit www.schoolpsychiatry.org.

Workplace Accommodation

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Examples of Common Workplace Accommodations
Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations:
Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be f...

Accommodations should be based on your needs and the employer’s resources. There is no standard list of reasonable accommodations, but here is a list of commonly provided workplace accommodations:

Job coach assistance in hiring and on the job mentoring as necessary. Job coach/mentor could be from an external agency or be from within the organization.

Flexible scheduling to accommodate effects of medications, time for appointments, more frequent breaks, switch to temporary part-time hours without fear of losing job.

Changes in supervision, for example how feedback and instruction are given, or having weekly supervision appointments to check in and prevent problems before they can happen.

In training, allowing more time for tasks to be learned, or allowing for individualized, one-on-one training.

Appropriate technology like a tape recorder to tape instructions, head phones to block out loud noise, etc.

Modifying work space or changing location so it is quieter, fewer distractions; allowing an employee to work at home.

Allowing an employee to exchange minor job tasks with others.

Rights and Responsibilities of the Employer & Employee

The Employer Should:

Create and maintain an atmosphere where people feel comfortable asking for accommodation, including providing information about the organization’s policies and creating ways for requests to happen confidentially.

Assume that the employee’s request for accommodation is made in good faith.

In a timely manner, work with the employee (and a professional, if necessary), to explore all options for accommodation.

Maintain records of the request and steps taken to deal with the request.

Maintain and respect confidentiality issues.

Pay the cost of the accommodations, including fees for any medical certificates required.

Request only information that is directly related to developing an appropriate accommodation.

Ensure that managers and supervisory staff will not tolerate any discrimination or harassment as a result of an illness or an accommodation.

The Employee Should

Tell the employer you need an accommodation, due to a disability, and give them the information they need to understand what the limitations are and what accommodations would address them.

The keys to taking care of youth mental health are to work towards building close and genuinely supportive relationships and promoting mental wellness, and to get help early should problems arise. This free guide was designed to help parents forge and strengthen those connections and support their youth's mental health.

OurHealthyMinds is about mental health. It celebrates the many ways we can be well, and honours the many ways we can experience mental illness - as an individual, a caregiver, a parent, a child or loved one.

Provides physical and mental health care to people (16+) who present for help for sexual assault and intimate partner violence. See website for other services provided including community education. more

Peer-run volunteer organization for individuals living with a mood disorder that provides resources, support groups, social and recreational activities for our members and their families and friends. more